Provider Demographics
NPI:1144524448
Name:KEEFAUVER, SUSAN PRICE (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PRICE
Last Name:KEEFAUVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN BAUTISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95045-0849
Mailing Address - Country:US
Mailing Address - Phone:831-623-1000
Mailing Address - Fax:
Practice Address - Street 1:525 VIA VAQUERO NORTE
Practice Address - Street 2:
Practice Address - City:SAN JUAN BAUTISTA
Practice Address - State:CA
Practice Address - Zip Code:95045-9590
Practice Address - Country:US
Practice Address - Phone:831-623-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0634532084N0400X, 2084N0600X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG063453Medicare UPIN